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Moremi Residential Services

Inclusion | Empowerment | Independence
5904 Thoreau Ave
260-435-9402
ayodeji@moremirs.com

NEW EMPLOYEE APPLICATION FORM

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT, but is merely intended to evaluate suitability for employment purposes only. It is the policy of Moremi Residential Services LLC to provide equal employment opportunities to all qualified persons without discrimination based on sex, race, color, religion, age, marital status, nationality, citizenship, sexual orientation, veteran status, or any other status protected under State and Federal Law. It is also the policy of Moremi Residential Services LLC to conduct pre-employment screening before making a job offer. If a job offer is made, employment may be contingent upon successful completion of a medical examination, which may also include the collection of bodily specimens through a facility-approved laboratory.

PERSONAL INFORMATION

PLEASE LIST YOUR CURRENT ADDRESS AND YOUR PAST TWO ADDRESSES
Undergraduate / College:
Graduate School:
EMPLOYMENT INFORMATION

Please answer all of the following questions. When necessary, note the question number and use an extra sheet of paper to provide more details.

EMPLOYMENT HISTORY
Please list your last three employers, beginning with the most recent.
Most Recent Employer:
Former Employer 1:
Former Employer 2:
Please answer all of the following questions. When necessary, note the question number and use an extra sheet of paper to provide more details.
Please list any professional licenses, designations, or certifications that may relate to the position applied for (e.g., Crisis Intervention, Medication Management, HHA, CNA, etc.). Include the date granted, issuing organization, and any other relevant information:
REFERENCES

Please list three individuals who can attest to your character, work ethic, and ability to work with a diverse population. Please include at least one professional reference. Do not list family members.

Reference 1:
Reference 2:
Reference 3:
APPLICANT'S CERTIFICATION AGREEMENT

Please read all statements carefully before signing.

  • I understand that I may be required to submit a copy of my resume, and that by submitting a resume, I understand that it will be used as only supporting and additional background information. A resume is not an authorized substitute for a completed employment application.
  • I understand that if I choose to complete only a portion of the required employment application, the information submitted may be inadequate from which to base an employment determination, and as a result, my application may not receive full consideration.
  • I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information. I also release Moremi Residential Services LLC from all liability that may result from making background investigations.
  • I certify that the facts and information outlined in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application or on any required documents will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.
  • I agree to conform to all existing and future workplace rules, regulations, policies, and procedures of Moremi Residential Services LLC if I am offered and accept a position.
  • I understand and agree that Moremi Residential Services LLC reserves the right to change any wage, hours of work, or working conditions at its sole discretion, at any time, as deemed necessary.
  • I understand that any employment offer is contingent upon my providing proof of identity and eligibility to work in the United States within 3 days of my start date, in conformance with the provisions of the Immigration Reform and Control Act of 1986.
  • I understand that any employment offer is contingent upon my providing proof of identity and eligibility to work in the United States within 3 days of my start date, in conformance with the provisions of the Immigration Reform and Control Act of 1986.

NEW EMPLOYEE PAYROLL CHECKLIST


Direct Deposit Information:

Moremi Residential Services LLC | Inclusion | Empowerment | Independence 5904 Thoreau Ave, Fort Wayne, IN 46815 | 260-435-9402 | ayodeji@moremirs.com